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Obstetrics

Antenatal Care (ANC) - Focused Approach

A planned program of care for pregnant women by skilled attendants, aiming for safe pregnancy and birth outcomes through screening, prevention, treatment, education, emergency planning, and identification of high-risk pregnancies. Uganda follows a 4-visit focused ANC model.

Also known as: ANC, Prenatal Care

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Referral and warning signs

When to refer

Refer women identified as High Risk (See OBS003). Refer women with danger signs or complications (bleeding, severe hypertension, reduced fetal movements, etc.). Refer women needing specialized investigations or management beyond facility capacity.

Red flags

  • Vaginal bleeding.
  • Severe headache / blurred vision.
  • Convulsions / Loss of consciousness.
  • High fever (>38.5 C).
  • Severe abdominal pain.
  • Difficulty breathing.
  • Reduced or absent fetal movements.

Signs and symptoms

  • Monitoring focuses on identifying existing problems, risks, and tracking maternal/fetal well-being.
  • Key monitoring points: Blood pressure, Symphysio-Fundal Height (SFH), Fetal heart rate, Fetal movements, Maternal weight, Oedema, Pallor.
  • Urine assessment for protein/glucose.

Risk factors

  • Refer to OBS003: High Risk Pregnancy criteria for specific risk factors identifying pregnancies needing closer monitoring.

Diagnosis

Clinical assessment

Assessment involves detailed history (medical, surgical, obstetric, social), physical examination (general, abdominal, vital signs, SFH, fetal assessment), and identification of risk factors or existing conditions based on expected findings for gestational age.

Investigations

  • All Visits: BP monitoring, SFH measurement.
  • Booking Visit (<14 weeks ideally): Haemoglobin (Hb), HIV test, Syphilis test (RPR/VDRL), Urinalysis (dipstick & microscopy), Blood group & Rhesus factor, Hepatitis B surface antigen (HBsAg) test. Consider Sickling test/G6PD if indicated. Malaria test (RDT/BS) if febrile.
  • Second Visit (24-28 weeks): Repeat Hb, Urine protein (if BP high or symptomatic), Repeat HIV test (per national guidelines). Consider Oral Glucose Tolerance Test (OGTT) if risk factors for Gestational Diabetes Mellitus (GDM). Malaria test if febrile. Rhesus antibody screen if Rh-negative.
  • Third Visit (30-32 weeks): Repeat Hb, Urine protein (if BP high or symptomatic). Malaria test if febrile.
  • Fourth Visit (>36 weeks): Repeat Hb, Urine protein (if BP high or symptomatic). Malaria test if febrile. Assess fetal presentation and position.

Diagnostic criteria

Ongoing assessment against expected gestational age milestones, identification of deviations, risk factors, or complications requiring specific management or referral.

Management

Non-pharmacological management

  • Health Promotion & Counseling (All Visits): Importance of ANC, Danger signs recognition, Nutrition and hygiene, Birth and emergency preparedness (involve partner/family), STI/HIV prevention & testing, Use of Insecticide-Treated Nets (ITNs), Avoidance of harmful substances (smoking, alcohol, drugs), Managing common pregnancy discomforts (See OBS002), Family planning, Newborn care preparation (breastfeeding, warmth, cord care, danger signs), Addressing Sexual and Gender-Based Violence (SGBV), Encouraging male partner involvement.
  • Monitoring maternal well-being and addressing concerns.

Pharmacological treatment

  • Routine Interventions:
  • - Iron/Folic Acid Supplementation: Ferrous sulphate (~60mg elemental iron) + Folic acid (400mcg) daily from booking until 6 months postpartum.
  • - Tetanus-Diphtheria (Td) Immunization: Provide according to national schedule (minimum 2 doses in first pregnancy, up to 5 doses for lifelong protection).
  • - Intermittent Preventive Treatment for Malaria in Pregnancy (IPTp-SP): Start after 13 weeks. Give Sulfadoxine/Pyrimethamine (SP - 3 tablets) monthly (at least 1 month apart) until delivery (minimum 3 doses). DOT at ANC. Not for HIV+ women on Cotrimoxazole.
  • - Deworming: Mebendazole 500mg single dose in 2nd and 3rd trimester.
  • Treatment of Identified Conditions: Manage anaemia, HIV (start ART Option B+), Hypertension, Malaria, Diabetes, UTIs, STIs etc. per specific guidelines.

Monitoring

Regular monitoring of BP, SFH, fetal heart rate, fetal movements. Follow up investigations (Hb). Monitor adherence to supplements/prophylaxis. Assess maternal well-being and address concerns.

Complications

  • Failure to detect/manage complications of pregnancy (e.g., pre-eclampsia, GDM, anaemia, infections).
  • Poor maternal/fetal outcomes (preterm birth, IUGR, stillbirth, maternal morbidity/mortality).
  • Missed opportunities for prevention (vaccination, IPTp, supplements) or treatment.

Prevention

  • Early booking for ANC (<14 weeks).
  • Adherence to recommended focused ANC schedule and interventions.
  • Effective health education and promotion.
  • Identification and management of risk factors.

Patient education

  • Importance of attending all scheduled ANC visits (minimum 4, ideally 8+).
  • Develop an individualized birth and emergency plan.
  • How to recognize danger signs and seek care promptly.
  • Advice on nutrition, hygiene, rest, avoiding harmful substances.
  • Importance of taking prescribed supplements (Iron/Folic acid) and prophylaxis (IPTp-SP, Td).
  • Benefits of skilled facility delivery.
  • Newborn care basics and importance of immediate postpartum care.
  • Family planning options postpartum.

Uganda-specific notes

Focused ANC (minimum 4 visits, aiming for 8+) is the standard. High burden of malaria, anaemia, HIV necessitates routine screening/prophylaxis. IPTp-SP is crucial. Option B+ (lifelong ART for all HIV+ pregnant/breastfeeding women) is policy. Male partner involvement is encouraged. Utilize ANC contact points for other health interventions.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.1, 16.1.1 (Goal-Oriented ANC Protocol Table)

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